ATLS | Trauma de abdomen | #ENARM2021 | 🩺Dr. Treviño

Trauma Abdominal y Pélvico: Evaluación y Mecanismos de Lesión

Introducción al Trauma Abdominal y Pélvico

• El Dr. Treviño introduce el módulo sobre trauma abdominal y pélvico, destacando su relevancia como una de las principales causas de muerte prevenibles.

• Se menciona que la evaluación del trauma puede verse comprometida por factores como consumo de alcohol, drogas o lesiones adyacentes.

Evaluación Inicial del Paciente

• Es crucial evaluar a los pacientes con lesiones por golpe directo, explosiones o heridas penetrantes en la cavidad torácica o abdominal.

• La anatomía básica del abdomen es revisada para identificar estructuras potencialmente alteradas durante el trauma.

Anatomía Relevante en Trauma

• Se delimita el abdomen anterior entre márgenes costales e inguinales, donde se asocian lesiones a vísceras huecas.

• La región toracoabdominal se define por líneas específicas que ayudan a identificar lesiones traumáticas penetrantes.

Mecanismos de Lesión en Trauma Contuso

• Se describen dos mecanismos principales: golpes directos (ej. accidentes automovilísticos) y lesiones por dispositivos de sujeción (cinturones).

• Las lesiones pueden incluir rupturas viscerales, hemorragias secundarias y peritonitis asociadas a traumas contusos.

Lesiones Comunes Asociadas al Trauma

• En trauma contuso, las vísceras más afectadas son el bazo (40%-55%), hígado (35%-45%) e intestino delgado (5%-15%).

• En trauma penetrante, las heridas por arma blanca afectan principalmente al hígado (40%), intestino delgado (30%) y diafragma (20%).

Consideraciones Finales sobre Traumas Penetrantes

Understanding Abdominal Trauma and Its Assessment

Types of Injuries Associated with Abdominal Trauma

• Up to 50% of abdominal trauma cases involve injuries to the small intestine, followed by 40% affecting the large intestine, and 30% involving liver injuries. Vascular structures like the abdominal aorta are implicated in about 25% of cases.

Mechanisms of Injury

• Explosive mechanisms combine penetrating and blunt trauma, often associated with other injuries such as traumatic brain injury (TBI) and thoracic trauma. A thorough clinical history is crucial for understanding the patient's condition.

Importance of Clinical History

• Gathering detailed information about the incident is vital, especially in cases like vehicular accidents. Key questions include impact speed and location to assess potential injuries accurately.

Assessing Fall Injuries

• For falls from heights, it’s essential to inquire about the height involved and whether substances were consumed prior to the fall, particularly if it was a suicide attempt.

Evaluating Penetrating Trauma

• In penetrating trauma cases, identifying the type of weapon used and counting wounds is critical. For explosive injuries, proximity to the blast site can indicate severity.

Physical Examination Protocol

• After taking a clinical history, a comprehensive physical examination should be conducted. This includes assessing for signs of injury while minimizing patient exposure time to prevent hypothermia.

Inspection Techniques

• During inspection, look for lesions or bruising in skin folds that may indicate underlying damage. The absence or presence of bowel sounds can also provide insights into visceral health.

Palpation Findings

• Palpation helps identify peritoneal irritation or localized pain; percussion can reveal physiological abnormalities such as dullness over organs indicating possible issues.

Managing Peritoneal Irritation

• If peritoneal irritation is present, avoid excessive manipulation during examination as this could exacerbate pain and affect ventilation status in patients.

Recognizing Pelvic Injuries

• Pelvic fractures are linked with unexplained hypotension; signs include scrotal hematoma or limb length discrepancies due to rotational effects from fractures.

Clinical Examination and Management of Pelvic Injuries

Overview of Rectal Examination

• The previous manuals included prostate palpation, but current practices have removed this step due to reliability concerns regarding urethral injuries.

• Rectal examination can reveal pelvic fractures and the presence of blood or hematic residues, indicating potential digestive hemorrhage from hollow viscus rupture.

Importance of Vaginal Examination

• In cases of suspected pelvic fractures, a vaginal examination is crucial to identify any canal injuries.

• It’s essential to determine if patients with transvaginal bleeding are menstruating, as retained tampons in shock states can lead to sepsis.

Assessment of Penetrating Injuries

• Up to 50% of penetrating injuries may be associated with intra-abdominal damage; thorough evaluation is necessary.

• A complete physical examination and detailed medical history are vital for primary assessment.

Catheterization Techniques

• Urinary catheters (e.g., Foley catheter) help relieve retention and monitor fluid therapy effectiveness in trauma patients.

• A full bladder enhances pelvic imaging quality; urinary catheters should be placed when suspecting pelvic injury.

Diagnostic Imaging Considerations

• Radiological assessments like abdominal X-rays are critical for identifying air under the diaphragm or other signs of trauma.

• Nasogastric tubes are contraindicated in suspected cribriform plate injuries due to risk of intracranial placement.

Managing Abdominal Trauma

• Blood in nasogastric output can indicate upper gastrointestinal bleeding related to abdominal organ ruptures.

• Initial chest X-rays are standard; however, high suspicion for abdominal injury warrants further imaging like upright abdominal films.

Diagnostic Approaches in Abdominal Trauma

Indications for Diagnostic Procedures

• The diagnostic approach is crucial for patients with altered sensorium, adjacent structural injuries, high suspicion of intestinal injury, or suggestive physical examination findings.

• The FAST (Focused Assessment with Sonography for Trauma) study is useful for detecting intraperitoneal fluid and can be repeated during the patient's stay in the emergency department.

• Peritoneal lavage is indicated when other imaging studies are unavailable; however, it requires gastric and urinary decompression and is contraindicated in advanced cirrhosis, morbid obesity, or pre-existing coagulopathy.

Comparison of Diagnostic Methods

• The umbilical approach for peritoneal lavage is recommended in suspected pelvic fractures to avoid direct access to hematomas and in advanced pregnancy cases.

• Evidence of gastrointestinal content during peritoneal lavage indicates surgical intervention; this includes the presence of vegetable fibers, bile, or over 10 cc of blood.

• A comparative table outlines advantages and indications for diagnostic methods: peritoneal lavage allows rapid detection of intestinal injuries without patient transport; FAST is non-invasive but operator-dependent; CT scans provide anatomical diagnosis but are costly and require patient movement.

Specific Indications for Each Method

• Peritoneal lavage is primarily indicated for hemodynamic alterations due to trauma. It’s essential when penetrating abdominal trauma does not necessitate immediate laparotomy.

• FAST should be used when there are hemodynamic changes associated with abdominal trauma without significant repercussions that would require urgent surgery.

• CT scans are indicated when suspecting retroperitoneal injuries without an immediate need for laparotomy.

Criteria for Urgent Laparotomy

• Patients requiring urgent laparotomy typically present with abdominal trauma accompanied by hypotension. Positive results from FAST or peritoneal lavage warrant immediate surgical intervention.

• Other indicators include gunshot wounds leading directly to surgery, signs of digestive hemorrhage, peritonitis, diaphragmatic air presence, or evidence of organ rupture.

Evaluation Strategies

• In stable patients without hemodynamic instability or visceral irritation, a conservative evaluation may be appropriate using initial imaging like FAST or CT before considering surgery based on subsequent findings.

Understanding Penetrating Abdominal Injuries

Mechanisms of Injury and Muscle Protection

• Back and flank muscles can mitigate the severity of penetrating injuries from firearms or knives, potentially limiting penetration depth.

• Specific lesions are referenced in manuals, indicating when to suspect certain injuries based on location, such as left-sided thoracic injuries.

Identifying Abdominal Injuries

• Renal injuries often correlate with frontal impacts in vehicular accidents or direct blows to the epigastric area; awareness is crucial for diagnosis.

• Gastric aspiration with blood or free air under the diaphragm on imaging suggests serious abdominal injury; pancreatic injuries may present variably in enzyme levels.

Genitourinary and Pelvic Injuries

• Hematomas and bruising in the back and flanks indicate potential genitourinary trauma, commonly associated with pelvic fractures.

• Understanding the anatomy of the genital diaphragm is essential as it relates to multisystemic injuries and pelvic fractures.

Types of Pelvic Compression Injuries

• Three types of compression injuries are identified: anteroposterior (15-20% occurrence), lateral (60-70%), and cervical displacement (5-15%).

• Anteroposterior compression leads to pubic symphysis separation, while lateral compression involves internal rotation affecting bladder and urethra.

Mortality Rates Associated with Pelvic Injuries

• Hypotension significantly increases mortality rates from pelvic fractures, ranging from 5% to 30%, escalating further if hypotension is present.

Trauma Management in Abdominal and Pelvic Injuries

Overview of Trauma Procedures

• The discussion begins with the description of agglutination techniques and maneuvers relevant to trauma cases, particularly when there is intra-abdominal bleeding. In such scenarios, a laparotomy may be performed if blood is present.

• In cases where extensive hemorrhage occurs without clear diagnosis, especially in older adults who are at higher risk for bleeding, angiographic studies are recommended. This approach helps identify the source of bleeding.

• The chapter on abdominal and pelvic trauma is noted as being extensive but not as detailed as thoracic trauma. It contains numerous data points that could easily be questioned in an academic or clinical setting.

• The speaker encourages feedback and questions regarding the material covered, indicating openness to corrections or clarifications from the audience.